Publications by authors named "Elisabetta Costantini"

128 Publications

Pain in Women: A Perspective Review on a Relevant Clinical Issue that Deserves Prioritization.

Pain Ther 2021 Mar 15. Epub 2021 Mar 15.

Headache, Science and Neurorehabilitation Centre, IRCCS Mondino Foundation, Pavia, Italy.

Introduction: Gender equity and gender medicine are opportunities not to be missed, and this Expert Group Opinion Paper on pain in women aims to review the treatment of pain conditions mainly affecting women, as well as the fundamental aspects of the different clinical response to drug treatment between the genders, and what can be done for gender-specific rehabilitation.

Methods: Perspective review.

Results: Genotypic and phenotypic differences in pain between the sexes are conditioned by anatomical, physiological, neural, hormonal, psychological, social, and cultural factors, such as the response to pharmacological treatment to control pain. The examination of these factors shows that women are affected by pain diseases more frequently and severely than men and that they report pain more frequently and with a lower pain threshold than men. Some forms of pain are inherently related to gender differences, such as pain related to the genitourinary system. However, other forms of chronic pain are seen more frequently in women than men, such as migraine, rheumatological, and musculoskeletal pain, in particular fibromyalgia.

Discussion: Research is needed into the pathophysiological basis for gender differences in the generation of acute pain and maintenance of chronic pain, including the factors that put women at higher risk for developing chronic pain. In addition, different specialties need to collaborate to develop gender-related diagnostic and therapeutic guidelines, and healthcare professionals need to upskill themselves in the appropriate management of pain using existing diagnostic tools and therapeutic options.
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http://dx.doi.org/10.1007/s40122-021-00244-1DOI Listing
March 2021

Peyronie's disease may negatively impact the sexual experience of a couple and female sexual function: a single center study.

Transl Androl Urol 2021 Feb;10(2):555-562

Andrology and Urogynecology Clinic, Santa Maria Terni Hospital, University of Perugia, Terni, Italy.

Background: Peyonie's disease (PD) mostly affects males in the fifth decade of life, with a prevalence in the general population ranging between 0.5% and 20.3%. The pathology of PD is characterized by fibrosis of the tunic albuginea of the cavernous bodies of the penis, with the presence of pain in the erection and penile deformity. This is associated with decreased sexual function for both participants. The objective of the study was to investigate the influence of PD pathology on both male patients' and their female partners' sexual spheres, and analyze changes in sexual function and perception following penile correction surgery.

Methods: Prospective study, we included male patients with PD and their female partner sexually active. Patients underwent corporoplasty with multiple plications. The male and female sexuality was evaluated before surgery and three months after male treatment by the Female sexual Function Index (FSFI); International Index of Erectile Function (IIEF); Visual Analogical Scale (VAS).

Results: From January 2018 to November 2019 we included 35 couple. The female subjects before partner's surgery presented dyspareunia, loss of sexual desire, inability to achieve orgasm, and sexual dissatisfaction. At three months after surgical treatment there was an improvement of sexual function in both male patients and female partners (desire P<0.0001, arousal P<0.0001, lubrification P<0.0001, orgasm P<0.0001, satisfaction P<0.0001, pain P<0.0001). As regarding male patients the pain decreased significantly (VAS score from 6 to 2.5), while there was no statistically significant improvement in erectile function (P=0.05).

Conclusions: Our findings suggest that a viable approach to treatment of PD patients that involves their partners could lead to better functional and psychological results.
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http://dx.doi.org/10.21037/tau-20-1067DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7947445PMC
February 2021

How Can the COVID-19 Pandemic Lead to Positive Changes in Urology Residency?

Front Surg 2020 24;7:563006. Epub 2020 Nov 24.

Department of Urology, IEO European Institute of Oncology IRCCS, Milan, Italy.

The COVID-19 outbreak, in a few weeks, overloaded Italian hospitals, and the majority of medical procedures were postponed. During the pandemic, with hospital reorganization, clinical and learning activities performed by residents suffered a forced remodulation. The objective of this study is to investigate how urology training in Italy has been affected during the COVID-19 era. In this multi-academic study, we compared residents' training during the highest outbreak level with their previous activity. Overall 387 (67.1%) of the 577 Italian Urology residents participated in a 72-h anonymous online survey with 36 items sent via email. The main outcomes were clinical/surgical activities, social distancing, distance learning, and telemedicine. Clinical and learning activity was significantly reduced for the overall group, and after categorizing residents as those working only in COVID hospitals, both "junior" and "senior" residents, and those working in any of three geographical areas created (Italian regions were clustered in three major zones according to the prevalence of COVID-19). A significant decrease in outpatient activity, invasive diagnostic procedures, and endoscopic and major surgeries was reported. Through multivariate analysis, the specific year of residency has been found to be an independent predictor for all response modification. Being in zone 3 and zone 2 and having "senior" resident status were independent predictors associated with a lower reduction of the clinical and learning activity. Working in a COVID hospital and having "senior" resident status were independent predictors associated with higher reduction of the outpatient activity. Working in zone 3 and having "senior" resident status were independent predictors of lower and higher outpatient surgical activity, respectively. Working in a COVID hospital was an independent predictor associated with robotic surgical activity. The majority of residents reported that distance teaching and multidisciplinary virtual meetings are still not used, and 44.8% reported that their relationships with colleagues decreased. The COVID-19 pandemic presents an unprecedented challenge, including changes in the training and education of urology residents. The COVID era can offer an opportunity to balance and implement innovative solutions that can bridge the educational gap and can be part of future urology training.
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http://dx.doi.org/10.3389/fsurg.2020.563006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7732553PMC
November 2020

Resveratrol-Based Multivitamin Supplement Increases Sperm Concentration and Motility in Idiopathic Male Infertility: A Pilot Clinical Study.

J Clin Med 2020 Dec 11;9(12). Epub 2020 Dec 11.

Andrologycal and Urogynecological Clinic, Santa Maria Terni Hospital, University of Perugia, 05100 Terni, Italy.

Background: It is known that a multitude of factors may lead to male factor infertility, but still, in the majority of cases, the cause remains largely idiopathic, reflecting poor understanding of the basic process of spermatogenesis and the mechanisms involved. Resveratrol is a polyphenol compound that displays several cellular aspects mainly associated with SIRT1-pathway activation and promotion of mitochondrial enhancer activities. In several animal models, resveratrol has shown positive effects on mitochondria and membrane potential. This could explain effects on sperm concentration and motility. The aim of this study is to evaluate the effects on the semen parameters of GENANTE, a multivitamin supplement containing 150 mg of resveratrol/day, in patients with idiopathic infertility.

Methods: This was a prospective single center clinical study. Twenty patients took a multivitamin supplement based on 150 mg of resveratrol (GENANTE), in the form of an oral tablet every 12 h, and were followed up at 1, 3, and 6 months after treatment. Pre- and post-treatment evaluation included history, clinical examination, semen analysis, hormonal determinations, and scrotal and prostatic ultrasound.

Results: Our preliminary pilot study demonstrated that the multivitamin supplement based on resveratrol improves sperm motility (48.3% ± 13.8 vs. 59.0% ± 12.8, = 0.0001) and concentration (22.6×10/m ± 9.5 vs. 25.7×10/mL ± 8.1, = 0.0001) after 3 and 6 months of treatment in men with idiopathic infertility.

Conclusion: Our data suggest that targeting the metabolic and energetic pathways involved in spermatogenesis and mitochondrial activity could lead to potential effects and counteract subfertility/infertility in men through a mitochondria dynamics mechanism.

Trial Registration Number: ClinicalTrials.gov registration identifier: NCT03864198, registered on 1 January 2019.
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http://dx.doi.org/10.3390/jcm9124017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7763587PMC
December 2020

A misdiagnosis of mesh extrusion treated as a psychiatric female pelvic pain.

Urologia 2020 Nov 27:391560320974890. Epub 2020 Nov 27.

Andrology and Urogynecology Clinic, Santa Maria Terni Hospital, University of Perugia, Perugia, Italy.

Introduction: Complications due to prosthetic surgery with mesh implantation may be misunderstood due to the insidious clinical presentation and inexperience of many surgeons if not adequately trained for the purpose.

Case Report: A 45-year-old female underwent a trans obturator tape procedure to correct severe stress urinary incontinence 3 months after surgery she developed urethral pain. The sling was partially removed, but the pain persisted. No residue sling was visualized by cystoscopies after surgery, and the pain was attributed to a psychiatric problem. She was treated with opioids, pregabalin without improvement of pain, until an extrusion of the sling into the urethra has been diagnosed by a careful urethrocystoscopy.

Conclusion: It has been treated in our department by the removal of the residual sling, plus urethroplasty. The patient was followed up at 6 months with resolution of the painful symptoms.
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http://dx.doi.org/10.1177/0391560320974890DOI Listing
November 2020

Is the Voided Volume at Office Uroflowmetry Physiological and Reliable? A Comparison between Voiding Diary and Uroflowmetry.

Urol Int 2020 22;104(11-12):908-913. Epub 2020 Jul 22.

Department of Urology, AOUI Verona, Verona, Italy.

Introduction: We compared voided volumes (VV) at voiding diaries (VD) and at uroflowmetry (UF) in men with lower urinary tract symptoms (LUTS).

Methods: This was a prospective, multicenter study. In a cohort of males with LUTS, VV reported in 3-day VD was compared to VV recorded at UF. Demographic data were analyzed. The patients were stratified according to VV. A sub-analysis dividing males by age strata was also performed.

Results: We enrolled 169 patients. Mean VV were higher at UF than at VD in the entire population and in each group, stratified by age. VV significantly decreased with aging. Males with the lowest threshold difference (50 mL) were 29%, with a moderate threshold difference (<100 mL) 55.6%, with an intermediate threshold difference 49.1% (51-150 mL), whereas 21.9% of men had a large threshold difference (>150 mL).

Discussion/conclusion: VV correlation between VD and UF was poor. A large part of men performed UF with VV which were poorly comparable to the habitual VV assessed by 3-day VD. Therefore, our results indicate the relevance to obtain more than 1 UF in these patients.
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http://dx.doi.org/10.1159/000509172DOI Listing
July 2020

Could COVID-19 have an impact on male fertility?

Andrologia 2020 Jul 21;52(6):e13654. Epub 2020 May 21.

Andrology and Urogynecology Clinic, Santa Maria Terni Hospital, University of Perugia, Terni, Italy.

The pandemic caused by Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to several hypotheses of functional alteration of different organs. The direct influence of this virus on the male urogenital organs is still to be evaluated. However some hypotheses can already be made, especially in the andrological field, for the biological similarity of the SARS-CoV and SARS-CoV2. As well as SARS-CoV, SARS CoV-2 uses the 'Angiotensin Converting Enzyme-2' (ACE2) as a receptor to enter human cells. It was found that ACE2, Angiotensin (1-7) and its MAS receptors are present, over in the lung, also in the testicles, in particular in Leydig and Sertoli cells. A first hypothesis is that the virus could enter the testicle and lead to alterations in testicular functionality. A second hypothesis is that the binding of the virus to the ACE2 receptor, could cause an excess of ACE2 and give rise to a typical inflammatory response. The inflammatory cells could interfere with the function of Leydig and Sertoli cells. Both hypotheses should be evaluated and confirmed, in order to possibly monitor fertility in patients COVID-19+.
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http://dx.doi.org/10.1111/and.13654DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7267130PMC
July 2020

Comparison between laparoscopic sacrocolpopexy with hysterectomy and hysteropexy in advanced urogenital prolapse.

Int Urogynecol J 2020 10 5;31(10):2069-2074. Epub 2020 Mar 5.

Andrological and Urogynecological Clinic, Santa Maria Terni Hospital, University of Perugia, Piazzale di Joanuccio 1, Posta Code 05100, Terni, Italy.

Introduction And Hypothesis: The aim of this study was to compare the outcomes in women who underwent laparoscopic sacrocolpopexy (LSC) with or without hysterectomy for pelvic organ prolapse (POP).

Methods: This was a single-centre prospective study. We included women with symptomatic POP (III-IV stage) who underwent LSC with or without hysterectomy. The preoperative evaluation included a history, clinical examination and urodynamic test; all patients completed FSFI, UDI-6 and IIQ-7 questionnaires. They were followed up at 1, 3, 6 and 12 months after surgery and then annually thereafter with the same preoperative flow chart. At the last visit, they also completed the PGI-I questionnaire.

Results: Between 2012 and 2016, a total of 136 patients with POP were included (82 in the LSC with hysterectomy group and 54 in the hysteropexy group). At a median follow-up of 65.3 months (36-84 months), there were improvements in the anatomical and functional outcomes of both groups without differences between the two approaches. The apical success rate was 100% in all women, without recurrence in either group; the anterior and posterior success rates of hysterectomy were higher than those of uterine preservation.

Conclusion: This study showed that there were no differences in the anatomical and functional outcomes between LSC with or without hysterectomy for POP.
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http://dx.doi.org/10.1007/s00192-020-04260-1DOI Listing
October 2020

Re: Long-term Results of Burch and Autologous Sling Procedures for Stress Urinary Incontinence in E-SISTEr Participants at 1 Site.

Eur Urol 2020 06 29;77(6):756. Epub 2020 Feb 29.

Andrology and Urogynecology Clinic, Santa Maria Terni Hospital, University of Perugia, Terni, Italy. Electronic address:

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http://dx.doi.org/10.1016/j.eururo.2020.02.022DOI Listing
June 2020

Italian real-life clinical setting: the persistence and adherence with mirabegron in women with overactive bladder.

Int Urol Nephrol 2020 Jun 21;52(6):1035-1042. Epub 2020 Feb 21.

Andrologycal and Urogynecological Clinic, Santa Maria Terni Hospital, University of Perugia, Piazzale di Joanuccio 1, 05100, Terni, Italy.

Introduction And Hypothesis: The aims of this study were to evaluate the persistence, the adherence on treatment with mirabegron, the reasons for the interruption in patients with overactive bladder syndrome (OAB) and their satisfaction.

Methods: This was an Italian multicentre prospective study. Four tertiary urological centers were involved. We included women with no neurogenic OAB symptoms already in therapy with once-daily mirabegron 50 mg for 1 month. They were followed up at 1, 3 and 6 months post-treatment with uroflowmetry with voiding diary for 3 days and post-void residual measurement. They completed self-administered Overactive Bladder questionnaire short form (OABq), Morisky Medication Adherence Scale-4 short form (MMAS), Patient Global Impression-Improvement questionnaire. Patients were divided in OAB wet and OAB dry groups, and in treatment-naive and treatment-experienced groups.

Results: Between January 2018 and July 2018, 80 patients with OAB were included. Fifteen (18.7%) patients continued the treatment for 6 months; 17.5% interrupted the therapy before 1 month: 30% within the third month, while, 33.7% after 1 month. The median time to discontinuation with mirabegron was 62.5 days. The mean adherence was 0.42 ± 0.33, median MMAS was 2 (0-4). The adherence was significantly greater in treatment-naïve (22.4%) than treatment-experienced (6.5%) patients, without statistically significant differences in the different OAB form. The cost is the main cause of interruption of therapy (50% of cases).There was an improvement of OABqSF score and PGI-I score.

Conclusion: In Italy, the cost compromises adherence and persistence of therapy with mirabegron despite the good functional outcomes.
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http://dx.doi.org/10.1007/s11255-020-02412-2DOI Listing
June 2020

AUTHOR REPLY.

Urology 2019 12;134:122-123

Andrology and Urogynecology Clinic, Santa Maria Terni, Terni Hospital, Department of Surgical and Biomedical Science, University of Perugia, Italy.

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http://dx.doi.org/10.1016/j.urology.2019.07.047DOI Listing
December 2019

Sexual and functional outcomes of prostate artery embolisation: A prospective long-term follow-up, large cohort study.

Int J Clin Pract 2020 Mar 10;74(3):e13454. Epub 2019 Dec 10.

Department of Medico-Surgical Biotechnologies, Department of Urology, Sapienza University of Rome, Latina, Italy.

Aim Of The Study: Among minimally invasive procedures for treating benign prostate hyperplasia (BPH) prostate artery embolisation (PAE) is described as safe and effective. Aim of this study is to report our results, focusing on sexual outcomes (erectile and ejaculatory functions sparing) of PAE in patients suffering from bladder outlet obstruction (BOO) secondary to BPH.

Methods: We prospectively enrolled and submitted to PAE subjects suffering from BOO secondary to BPH. All patients were not suitable for surgery or declined invasive approaches. All subjects were preoperatively and postoperatively (3, 6, 12 and 18 months after) evaluated by urinary flowmetry, post voiding residual volume, prostate volume, serum PSA levels, International Index of Erectile Function, International Prostate Symptom Score and QoL scores.

Results: PAE was performed in 147 patients (mean age 72.5 y.o.). PAE was technically successful in all patients. The procedure lasted a mean time of 94.3 minutes, with a mean fluoroscopic time of 42.5 minutes. Twelve months follow-up data were available for all patients, while 126 patients (85%) completed the 18 months follow up. At 12 months follow up, the mean IPSS and QoL scores significantly decreased, and all the objective parameters (mean Qmax, PVR and prostate volume) reported a significant improvement. A total of 130 patients (88.5%) at 12 months reported the antegrade ejaculation preserved, and a slight not significant improvement of IIEF scores. The 18 months after PAE outcomes confirmed the significant improvement of all the variables evaluated (even for PSA values and IIEF scores). No major complications occurred.

Conclusions: Our results evidence prostate artery embolisation as highly feasible and safe procedure with interesting outcomes. In particular, in our study PAE reported promising results in preserving antegrade ejaculation and erectile function. Our data are in line with the literature, confirming how PAE reduces obstructive symptoms in BPH patients not suitable or refusing standard surgical approaches.
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http://dx.doi.org/10.1111/ijcp.13454DOI Listing
March 2020

A Prospective Comparative Study of the Feasibility and Reliability of Telephone Follow-Up in Female Urology: The Patient Home Office Novel Evaluation (PHONE) Study.

Urology 2020 Feb 11;136:82-87. Epub 2019 Nov 11.

Dept. of Urology Azienda Ospedaliera Universitaria Integrata, Verona, Italy.

Objective: To determinate the feasibility, reliability, and patient satisfaction of telephonic follow-up in women treated for stress urinary incontinence (SUI) or pelvic organ prolapse (POP): Patient-Home-Office-Novel-Evaluation (PHONE) study.

Methods: This is a prospective comparative study in women following surgery for SUI underwent middle urethral sling (MUS) (Group A), or symptomatic anterior vaginal wall (AVW) defect underwent AVW repair (fascial/mesh/biomesh) (Group B). The 1-year follow-up included a telephonic interview using a checklist and validated questionnaires followed by a standard outpatient clinic visit 7-12 days later including: an interview, validated questionnaires, objective examination, and score satisfaction with the telephone follow-up.

Results: We enrolled 420 pts: 215 for SUI in Group A, and 205 for POP in Group B. SUI recurrence was 19.1% and 11.6% at the telephone and office follow-up, respectively. De-novo urgency urinary incontinence rate was 7.5%. Telephone follow-up was able to detect POP recurrence and related symptoms. Tape and mesh extrusions were detected only at the objective evaluation: 1.9% and 4.4% respectively. No difference was found at the questionnaires. Satisfaction with the telephone follow-up was high.

Conclusion: Due to the wrongly interpretation of de-novo urge urinary incontinence as a recurrence of SUI, a telephone interview may lose reliability in case of reported incontinence. Thus, telephone follow-up was feasible and reliable in women not reporting incontinence. In patients treated for POP the phone interview was a valid tool only in case of no-prosthetic surgery due to the absence of extrusion in these cases.
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http://dx.doi.org/10.1016/j.urology.2019.10.021DOI Listing
February 2020

Robot-assisted Vs Laparoscopic Sacrocolpopexy for High-stage Pelvic Organ Prolapse: A Prospective, Randomized, Single-center Study.

Urology 2019 12 26;134:116-123. Epub 2019 Sep 26.

Andrology and Urogynecology Clinic, Santa Maria Terni, Terni Hospital, Department of Surgical and Biomedical Science, University of Perugia, Italy.

Objective: To compare robot assisted to laparoscopic sacrocolpopexy, in terms of efficacy, in the treatment of high-stage pelvic organ prolapse.

Methods: This was a noninferiority prospective randomized trial conducted in a tertiary Urology unit, comparing robot assisted and laparoscopic sacrocolpopexy in patients with symptomatic prolapse stage III and IV, according to the Pelvic Organ Prolapse quantification. All participants provided written informed consent at enrolment. The primary outcome was prolapse objective cure rate. Secondary outcomes included prevalence of urinary, anorectal and sexual symptoms, UDI-6, IIQ7 and FSFI scores, and maximum flow rate. Operative times, intraoperative blood loss, length of hospital stay, postsurgery pain, patient satisfaction as well as surgical and mesh complications were assessed. The Mann-Whitney and Wilcoxon tests for unpaired and paired data, respectively, were used to compare ordinal and nonnormally distributed continuous variables. Categorical data were analyzed by the McNemar, chi-square or Fisher exact test. Two-tailed P <.05 was considered significant.

Results: One hundred patients were randomized. At a mean follow-up of 24.06 months the cure rate for the apical compartment was 100% with both approaches. There were no significant between-group differences in any of the secondary outcomes with the only exception of C/D point values, where results were significantly better in the robot-assisted group. Overall surgical procedure time was longer in the robot-assisted group. The main limitation of our study is the single-centre design and the inclusion of docking time in robotic-procedure surgical time calculations.

Conclusion: Robot-assisted sacrocolpopexy provides outcomes comparable to those of laparoscopic with 100% anatomic correction of the apical compartment.
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http://dx.doi.org/10.1016/j.urology.2019.07.043DOI Listing
December 2019

No Treatment Required for Asymptomatic Vaginal Mesh Exposure.

Urol Int 2019 21;103(2):223-227. Epub 2019 Jun 21.

Department of Andrology and Urogynecological Clinic, Santa Maria Terni Hospital, University of Perugia, Perugia, Italy.

Introduction: There is no specific recommendation for the management of asymptomatic vaginal mesh erosions post antiincontinence or prolapse surgery, but revision or excision may represent overtreatment. We hypothesize that asymptomatic vaginal exposures remain asymptomatic during follow-up and do not require any intervention.

Methods: We evaluated a "no treatment" approach by prospectively following-up women with asymptomatic vaginal exposures after antiincontinence and pelvic organ prolapse surgery. After a 1-month course of vaginal oestrogen, they underwent the "wait and see" protocol. It consisted of no treatment. Women were followed-up every 3 months, for the first year and then every 6 months with history, clinical examination with measurement of size of the exposure, and the evaluation of possible infection signs or vaginal discharge.

Results: Forty women were followed-up for a median of 33.52 months (range 8-48 months). All exposures were ≤1 cm (mean 6.5 ± 1.5 mm, range 4-10 mm), patients were asymptomatic and without pain. During the observation period, the size of the exposure did not change and all women remained asymptomatic.

Discussion/conclusion: No treatment seems to be required for asymptomatic and small vaginal mesh exposures after prolapse or incontinence surgery.
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http://dx.doi.org/10.1159/000501287DOI Listing
February 2020

Successful treatment with pollen extract of hematospermia in patients with xanthogranolomatous prostatitis.

Arch Ital Urol Androl 2019 Mar 29;91(1):22-24. Epub 2019 Mar 29.

Sapienza University of Rome, Faculty of Pharmacy and Medicine, Department of Medico-Surgical Sciences and Biotechnologies, Urology Unit, Latina; Uroresearch, no profit Association for Research in Urology, Latina.

Introduction: The aim of this study was to report our experience in the management of hematospermia observed in 16 patients suffering from xanthogranulomatous prostatitis.

Methods: Recurrent episodes of hematospermia were the onset symptom in all patients, and in 25% of patients it was combined with fever. All patients reported PSA value elevation and the digital rectal examination (DRE) revealed an increase of the gland size and of its consistency in all cases. In all patients, the hematospermia was treated with the oral administration of two tablets of pollen extract in a single (1 g) dose daily for 30 days.

Results: Sixteen patients were observed between 2008 and 2016, referring hematospermia, progressive lower urinary tract symptoms (LUTS), and serum PSA level increase. To exclude the prostate cancer presence all patients were submitted to transperineal TRUS guided biopsy. In all the patients complete resolution of hematospermia was achieved treatment with pollen extract. All patients were subsequently treated for LUTS (alpha-adrenergic blockers), but none reported any significant improvement of symptoms. Basing on these pieces of evidence, after 90 days of alpha-blockers therapy, all patients underwent bipolar TURP. Histological examination of resected prostatic tissue revealed in all patients the diagnosis of xanthogranulomatous prostatitis.

Conclusions: Patients with xanthogranulomatous prostatitis especially experience irritative symptoms, sometimes combined with fever or hematospermia. Hematospermia as the onset symptom has not been reported so far. The administration of the pollen extract for 30 days was associated with a complete resolution of hematospermia.
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http://dx.doi.org/10.4081/aiua.2019.1.22DOI Listing
March 2019

Transobturator Tape: Over 10 Years Follow-up.

Urology 2019 Jul 16;129:48-53. Epub 2019 Mar 16.

Andrology and Urogynecology Clinic, Santa Maria Terni Hospital, University of Perugia, Perugia, Italy.

Objectives: To assess subjective and objective outcomes in incontinent patients following "out-in" TOT, at >10-year follow-up; to evaluate effect on quality of life and other urinary symptoms, late adverse events and predictive factors for failure.

Methods: This single-centre prospective study evaluated women with "complicated" or "uncomplicated" stress urinary incontinence (SUI) following "out-i"' TOT between 2003 and 2007. The pre-op work-up comprised: history; pelvic examination; cough stress test; urodynamic study; UDI-6; and King's Health questionnaires. Work-up was the same as pre-op plus the Patient Global Impression of Improvement scale with final follow-up in 2017.

Results: One hundred thirty six consecutive patients underwent TOT; at final follow-up (mean 145 months) we evaluated 123. Cure rates: objective: 78.9%; subjective: 62.6%; no significant deterioration in SUI cure rates over time. Urgency and urgency urinary incontinence (UUI) significantly reduced. Voiding dysfunction increased without urodynamic obstruction. De novo urgency appeared in 7.3% and de novo UUI in 4.1%. In the 31 uncomplicated SUI patients, the objective cure rate was 87.1% and the subjective cure rate was 72.2%. De novo urgency appeared in 9.7% and de novo UUI in 3.2%. Nine King's Health questionnaires domains saw statistically significant improvements. In univariate analysis, pre-op wet OAB was associated with subjective recurrent SUI (P < .038) and parity >2 was associated with objective recurrent SUI (P = .023). We had 5 cases of partial mesh exposure.

Conclusion: Cure rates are satisfactory, 10 years after TOT surgery, with good quality of life and few major complications. However, some postoperative symptoms may be caused by long-term treatment failure or by advancing age or another pathology.
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http://dx.doi.org/10.1016/j.urology.2019.03.003DOI Listing
July 2019

Transobturator mid-urethral sling in females with stress urinary incontinence and detrusor underactivity: effect on voiding phase.

Int Urogynecol J 2019 09 4;30(9):1519-1525. Epub 2019 Feb 4.

Andrology and Urogynecology Clinic, Santa Maria Terni Hospital, University of Perugia, Perugia, Italy.

Introduction And Hypothesis: To assess whether detrusor underactivity (DU) is a risk factor for voiding dysfunction (VD) after transobturator tape (TOT) and if a detrusor pressure at maximum flow (PdetQmax) value predicts postoperative VD in DU patients. Also, we examined uncomplicated patients for postoperative VD.

Methods: This is a prospective long-term study on SUI patients who underwent TOT. Exclusion criteria were preoperative POP stage ≥ 2, previous anti-incontinence surgery and comorbidities. Patients were grouped by detrusor contractility using the projected isovolumetric pressure (PIP) index (PdetQmax + maximum flow rate) with values of 30-75 cmHO indicating normal contractility. Follow-up was at 1, 3, 6 and 12 months, and then annually. All patients underwent a stress test and responded to the Urogenital Distress Inventory questionnaire and to the King's Health Questionnaire. The subjective cure was evaluated using the Patient Global Impression of Improvement. We determined the diagnostic accuracy of PdetQmax levels using ROC curve analysis, with a cut-off point calculated for optimal sensitivity and specificity.

Results: In 2007-2013, 118 patients underwent TOT. We included 50 in the undercontractility group (G1) and 50 in the normocontractility group (G2). Continence rates were 82% in G1 and 84% in G2 (mean follow-up 76 months). VD increased from 18 to 36% (p < 0.05) in G1 and from 14 to 16% (p = 0.198) in G2. De novo VD was 28% in G1 and 2% in G2. In the G1 group PdetQmax ≤ 12 cmHO predicted postoperative VD with 71.4% specificity and 80.0% sensitivity.

Conclusions: DU adversely affects the voiding phase of micturition after TOT. In DU patients, PdetQmax ≤ 12 cmHO predicts postoperative VD.
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http://dx.doi.org/10.1007/s00192-019-03871-7DOI Listing
September 2019

Urodynamic findings and functional outcomes after laparoscopic sacrocolpopexy for symptomatic pelvic organ prolapse.

Int Urogynecol J 2019 04 2;30(4):589-594. Epub 2019 Feb 2.

Andrology and Urogynecological Clinic, Santa Maria Hospital Terni, University of Perugia, Piazzale Tristano di Joanuccio, Terni, Italy.

Introduction And Hypothesis: The aim of this study was to evaluate the functional outcomes and urodynamic findings after laparoscopic sacrocolpopexy (LSC) in patients with stages II-IV pelvic organ prolapse (POP).

Methods: In this single-center prospective study, we evaluated 63 women (mean age 62.5 ± 7.5 years) women with symptomatic and advanced POP (stage II-IV) who underwent LSC without concomitant anti-incontinence surgery. The preoperative evaluation incuded history, clinical examination, and urodynamic testing. Women were followed up at 1, 3, 6, and 12 months after surgery and then annually using history, examination, and uroflowmetry. At 6 months, we performed urodynamic testing. To evaluate urinary symptoms, we used the Urogenital Distress Inventory (UDI)-6 questionnaire before and 6 months after surgery.

Results: Median follow- up was 22 months (range 8-48). After surgery, maximum flow (Q) significantly improved compared with baseline (14.17 ± 2.3 vs 27 ± 8.4 ml/s; p = 0.02), and the percentage of patients with elevated postvoid residual (PVR) significantly decreased (33.3% vs 11.1%; p = 0.001). Detrusor overactivity and bladder outlet obstruction disappeared in 73.6% and 85.7% of patients, respectively, while detrusor underactivity persisted in 66.6% of women. Twenty women (31.7%) reported stress urinary incontinence (SUI) before surgery (14 clinically evident and 6 as occult form), which persisted in only 7/20 (11%) patients following LSC, with no de novo cases. The most common preoperative symptoms were voiding symptoms, present in 42/63 (66.6%) patients, which resolved in 36 (85.7%). The overactive bladder syndrome disappeared in 60% of women, with no de novo cases. Results were reflected by a significant decrease in UDI-6 score from a median of 16 (0-45) at baseline to 5.5 (0-17) at the final follow-up (p = 0.001). The domain on storage symptoms (median 3 vs 1) and voiding symptoms (median 3 vs 1) of UDI-6 showed an improvement after surgery (p = 0.001).

Conclusions: The urodynamic finding showed that LSC in women with advanced POP provides good functional outcomes.
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http://dx.doi.org/10.1007/s00192-019-03874-4DOI Listing
April 2019

Uterus Preserving Prolapse Repair: How Long does it Last?

Urol Int 2019 23;102(3):319-325. Epub 2019 Jan 23.

Andrology and Urogynecological Clinic, Santa Maria Hospital Terni, University of Perugia, Terni, Italy,

Background: The preservation of the uterus has an important role in the pelvic organ prolapse (POP) surgery.

Objectives: The aim of this study is to assess the long-term anatomical and functional outcomes of abdominal hysterosacropexy.

Methods: Prospective study. A series of women who underwent open abdominal hysterosacropexy for high-stage POP with a minimum 75-month follow-up were included.

Results: Data on 51 patients were included. Median follow-up was 136.7 months (range 75.8-258 months). Apical prolapse cure rate was 100%. The success rate for anterior and posterior vaginal compartment was 96 and 94% respectively. Urinary and sexual symptoms significantly improved. Ninety-two percentage of the women were "extremely" or "very much improved" with the operation.

Conclusion: This study confirms that abdominal hysterosacropexy is a good surgical option with durable results for the management of POP in women who wish to preserve their uterus.
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http://dx.doi.org/10.1159/000496346DOI Listing
December 2019

Coital Incontinence in Women With Urinary Incontinence: An International Study.

J Sex Med 2018 10 20;15(10):1456-1462. Epub 2018 Sep 20.

Department of Surgical and Biomedical Science, Andrological and Urogynecological Clinic, University of Perugia, Terni, Italy. Electronic address:

Introduction: Coital urinary incontinence (CUI) is not much explored during clinical history, and this could lead to an underestimation of the problem.

Aim: To evaluate the prevalence and clinical risk factors of CUI in women with urinary incontinence (UI), and to measure the impact of CUI on women's sexuality and quality of life.

Methods: This was a multicenter international study, conducted in Italy, Greece, the United States, and Egypt. Inclusion criteria were: sexually active women with UI and in a stable relationship for at least 6 months. Exclusion criteria were: age <18 years and unstable relationship. The UI was classified as stress UI (SUI), urgency UI (UUI), and mixed UI (MUI). Women completed a questionnaire on demographics and medical history, in particular on UI and possible CUI and the timing of its occurrence, and the impact of CUI on quality and frequency of their sexual life.

Main Outcome Measures: To evaluate the CUI and its impact on sexual life we used the open questions on CUI as well as the International Consultation on Incontinence questionnaire and Patient Perception of Bladder Condition questionnaire.

Results: In this study 1,041 women (age 52.4 ± 10.7 years) were included. In all, 53.8% of women had CUI: 8% at penetration, 35% during intercourse, 9% at orgasm, and 48% during a combination of these. Women with CUI at penetration had a higher prevalence of SUI, women with CUI during intercourse had higher prevalence of MUI with predominant SUI, and women with CUI at orgasm had higher prevalence of UUI and MUI with predominant UUI component. Previous hysterectomy was a risk factor for CUI during any phase, while cesarean delivery was a protective factor. Previous failed anti-UI surgery was a risk factor for CUI during penetration and intercourse, and body mass index >25 kg/m was a risk factor for CUI at intercourse. According to International Consultation on Incontinence questionnaire scores, increased severity of UI positively correlated with CUI, and had a negative impact on the quality and frequency of sexual activity.

Clinical Implications: This study should encourage physicians to evaluate the CUI; in fact, it is an underestimated clinical problem, but with a negative impact on quality of life.

Strengths & Limitations: The strength of this study is the large number of women enrolled, while the limitation is its observational design.

Conclusion: CUI is a symptom that can affect sexual life and should be investigated during counseling in all patients who are referred to urogynecological centers. Illiano E, Mahfouz W, Giannitsas K, et al. Coital Incontinence in Women With Urinary Incontinence: An International Study. J Sex Med 2018;15:1456-1462.
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http://dx.doi.org/10.1016/j.jsxm.2018.08.009DOI Listing
October 2018

Pelvic muscle floor rehabilitation as a therapeutic option in lifelong premature ejaculation: long-term outcomes.

Asian J Androl 2018 Nov-Dec;20(6):572-575

Urology Unit, Department of Medico-Surgical Sciences and Biotechnologies, ICOT, Faculty of Pharmacy and Medicine, "Sapienza" University of Rome, Latina (LT) 04100, Italy.

The aim of the study was to evaluate the long-term outcomes of pelvic floor muscle (PFM) rehabilitation in males with lifelong premature ejaculation (PE), using intravaginal ejaculatory latency time (IELT) and the self-report Premature Ejaculation Diagnostic Tool (PEDT) as primary outcomes. A total of 154 participants were retrospectively reviewed in this study, with 122 completing the training protocol. At baseline, all participants had an IELT ≤60 s and PEDT score >11. Participants completed a 12-week program of PFM rehabilitation, including physio-kinesiotherapy treatment, electrostimulation, and biofeedback, with three sessions per week, with 20 min for each component completed at each session. The effectiveness of intervention was evaluated by comparing the change in the geometric mean of IELT and PEDT values, from baseline, at 3, 6, and 12 months during the intervention, and at 24 and 36 months postintervention, using a paired sample 2-tailed t-test, including the associated 95% confidence intervals. Of the 122 participants who completed PFM rehabilitation, 111 gained control of their ejaculation reflex, with a mean IELT of 161.6 s and PEDT score of 2.3 at the 12-week endpoint of the intervention, representing an increase from baseline of 40.4 s and 17.0 scores, respectively, for IELT and PEDT (P < 0.0001). Of the 95 participants who completed the 36-month follow-up, 64% and 56% maintained satisfactory ejaculation control at 24 and 36 months postintervention, respectively.
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http://dx.doi.org/10.4103/aja.aja_30_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6219291PMC
October 2019

Counseling in urogynecology: A difficult task, or simply good surgeon-patient communication?

Int Urogynecol J 2018 07 29;29(7):943-948. Epub 2018 May 29.

University of Chicago, Chicago, IL, USA.

Surgical treatments for pelvic organ prolapse (POP) and urinary incontinence (UI) have greatly changed in recent years. Prompted by increases in reports of adverse outcomes in relation to such treatments, several scientific societies and researchers have emphasized providing patients with thorough counseling before treating them. Patient-centered communication has become the gold standard for excellence in clinical care. This challenges clinicians to be cognizant of their patients' perspectives, motivations, expectations, fears, concerns, and social contexts to enable them to reach a shared understanding with patients. Considering this, urogynecology counseling represents a crucial process through which women can gain a clear understanding of their clinical condition and the risks and benefits of potential treatment options. However, many urogynecologists believe that proposing a treatment and providing only enough detail to secure informed consent constitutes counseling. This article is intended to describe good counseling for women undergoing urogynecological surgery and to suggest optimal methodologies for implementation.
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http://dx.doi.org/10.1007/s00192-018-3673-8DOI Listing
July 2018

"Nested Type" Bladder Cancer: Myth or Reality?

Urol Int 2018 17;100(4):491-492. Epub 2018 Jan 17.

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http://dx.doi.org/10.1159/000486533DOI Listing
November 2018

Mixed urinary incontinence: A prospective study on the effect of trans-obturator mid-urethral sling.

Eur J Obstet Gynecol Reprod Biol 2018 Feb 6;221:64-69. Epub 2017 Dec 6.

Department of Urology and Andrology Clinic, Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy.

Objectives: It is hypothesized that urethral dysfunction is central in mixed urinary incontinence (MUI) in women, since urine entering the proximal urethra under increased intra-abdominal pressure provokes a urethro-detrusorial reflex and involuntary detrusor contraction. Mid-urethral slings have been proposed as a solution. Our primary objective was to evaluate the long-term subjective and objective outcomes on continence and other urinary symptoms of a trans-obturator mid-urethral sling (TOT) procedure. Our secondary objectives were to determine its impact on quality of life (QoL), and to investigate which factors influence outcomes.

Study Design: This is a single-centre prospective study on a consecutive series of 86 women who underwent TOT for MUI as defined by ICS/IUGA. Since the definition of MUI that we used is symptom-based, we included patients both with and without associated detrusor overactivity. All patients underwent placement of Monarc Subfascial Hammocks.

Statistical Analysis: We used the McNemar chi-square test, the paired t-test and Fisher's exact test. A logistic regression model and odds ratios were used to assess age, parity, body mass index, menopausal status, preoperative detrusor over-activity, and detrusor pressure at maximum flow as possible factors for treatment failure. Only those that were statistically significant in the univariate analysis were included in the multivariate analysis.

Results: With a mean follow-up of 59 months, SUI was cured objectively in 83.7% of patients and subjectively in 87.2%. Three patients underwent further anti-incontinence surgery. The continence rates were 74.4% for urgency urinary incontinence (UUI) and 66.3% for SUI-UUI. The patient-reported success rate was 87.2% ('much better' or 'very much better' on Patient Global Impression of Improvement scale). There were statistically significant improvements in all domains except general health. The univariate analysis found no significant risk factor for persistence of SUI. Median age >60 years and menopause were predictive for persistence of UUI. Median and mean age >60 years were predictive of persistence of overall incontinence. In the multivariate model, all variables lost their statistical significance.

Conclusion: Our study demonstrates TOT surgery can be performed for patients with MUI following unsuccessful conservative therapy. We also demonstrate that menopause and age >60 are risk factors for failure. This should be considered when counselling preoperatively.
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http://dx.doi.org/10.1016/j.ejogrb.2017.12.003DOI Listing
February 2018

Sacrocolpopexy with polyvinylidene fluoride mesh for pelvic organ prolapse: Mid term comparative outcomes with polypropylene mesh.

Eur J Obstet Gynecol Reprod Biol 2018 Jan 22;220:74-78. Epub 2017 Nov 22.

Department of Urology and Andrology Clinic, Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, 06121, Italy.

Objective: The aim of this study was to compare the surgical, anatomical, and functional outcomes of sacrocolpopexy (SCP) using polyvinylidene fluoride (PVDF) mesh versus SCP using the standard polypropylene (PP) mesh.

Study Design: This was a retrospective single centre case-control study including female patients who underwent laparoscopic or abdominal SCP for POP with either PP (Cousin Biotech) or PVDF (DynaMesh-PRS) mesh between March 2005 and May 2015. Anatomical outcomes were assessed by the Pelvic Organ Prolapse Quantification (POP-Q) system. Functional outcomes included voiding and storage urinary symptoms (VS and SS, respectively), urgency and stress urinary incontinence (UUI and SUI) and sexual dysfunction (SD). Symptoms and their impact on patients' quality of life (QoL) were assessed using validated questionnaires as Incontinence Impact Questionnaire (IIQ-7), Urinary Distress Inventory (UDI-6) and Female Sexual Function Index (FSFI). Global patient perception of improvement (PGI-I questionnaire) and mesh erosion rates were also recorded.

Results: Of the 166 patients enrolled, 136 could be included in the analysis: 73 in the PP group and 63 in the PVDF group. The mean follow-up was 94± 17.31 months for the PP and 25.6± 13.8 months for the PVDF group. There were no statistically significant differences in patient demographics and preoperative clinical characteristics. Postoperative anatomical correction were not significantly different between the two groups. The PVDF group showed superior results in term of storage symptoms (PVDF=0% versus PP=8.2%; p=0.02) and lower rate of sexual dysfunction (PVDF=0% versus PP=16,4%; p=0.001). Only 1 patient in PP group and 2 in PVDF group (p=0.47) presented a mesh exposure. There was no statistical difference in PGI-I scores (PP=1.5±1.0 vs PVDF=1.8±0.5; p=0.40).

Conclusions: Our findings suggest that both meshes can be safely and effectively used with good anatomical outcomes. Interestingly, PVDF use was associated with significantly less storage symptoms and sexual dysfunction.
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http://dx.doi.org/10.1016/j.ejogrb.2017.11.018DOI Listing
January 2018

Urological dysfunction in young women: an inheritance of childhood?

BJU Int 2018 03 21;121(3):453-457. Epub 2017 Dec 21.

Department of Surgical and Biomedical Sciences, Urology and Andrology Clinic, University of Perugia, Perugia, Italy.

Objective: To investigate the correlation of a history of lower urinary tract symptomatology during childhood with lower urinary tract dysfunction in young adult women.

Subjects And Methods: This was a multicentre, prospective, case-control study conducted between April 2013 and November 2015. A total of 300 women, aged 18-40 years, participated. The case group comprised women attending urogynaecology clinics for various lower urinary tract complaints and the control group was recruited from a healthy population. Exclusion criteria were designed to avoid common causes of lower urinary tract dysfunction and symptoms and included diabetes mellitus, neurological disease and pelvic inflammatory disease. All women completed a self-administered 77-item questionnaire, exploring childhood urological and bowel history, as well as current urological, bowel and sexual symptoms. Statistical analysis was performed using chi-squared and Fisher's exact tests to compare categorical variables. Multivariate logistic regression models were fit for the prediction of the adult outcomes, incorporating as explanatory variables all those that showed a significant P value in bivariate analysis. P values < 0.05 were considered statistically significant.

Results: Women with childhood urinary voiding and storage symptoms had a higher prevalence of these symptoms in adult life compared with women without such history. Women with urinary tract infections (UTIs) during childhood had a higher incidence of adult UTIs compared with women without this problem in childhood.

Conclusions: Lower urinary tract dysfunction in childhood seems to 'persist' in young adult life but the implications of this finding in clinical practice need to be defined in future studies.
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http://dx.doi.org/10.1111/bju.14081DOI Listing
March 2018

Increased risk of erectile dysfunction in men with multiple sclerosis: an Italian cross-sectional study.

Cent European J Urol 2017 4;70(3):289-295. Epub 2017 Aug 4.

Urology Service, University of Campania L. Vanvitelli, Naples, Italy.

Introduction: Sexual dysfunctions (SDs) are common, but often underestimated symptoms in men with multiple sclerosis (MS). The most common sexual complaint in a multiple sclerosis male is erectile dysfunction (ED). The aim of this observational, cross-sectional study was to assess the prevalence of erectile dysfunction (ED) and its relationship with neurological disability, depression, urodynamic findings and lower urinary tract symptoms (LUTS) in these patients.

Material And Methods: From January 2014 to January 2016, there were 101 consecutive male patients with a diagnosis of Multiple Sclerosis according to the McDonald revised criteria and stable sexual relationships were included. Patients were evaluated with the International Index of Erectile Function (IIEF-15), Sexual Quality of Life Questionnaire-Male version (SQoL-M), International Prostate Symptom Score (I-PSS) and the Beck Depression Inventory-II (BDI-II). Neurological impairment was assessed using the Expanded Disability Status Scale (EDSS). The presence of Detrusor Overactivity (DO), Detrusor Underactivity (DU) and Detrusor Sphincter Dyssynergia (DSD), was defined by International Continence Society (ICS) criteria.

Results: Erectile dysfunction (ED) defined according to the erectile function (EF)-subdomain score ≤25 was present in 75 patients (74.25%). Univariate regression analysis showed that Sexual Quality of Life Questionnaire-Male version (P <0.0001), age (P = 0.021), Expanded Disability Status Scale score (P = 0.001), Beck Depression Inventory-IIscore (P = 0.001),International Prostate Symptom Score (P = 0.001), Detrusor Underactivity (P = 0.002), Multiple Sclerosis-Secondary Progressive (P = 0.002) was significantly associated with erectile dysfunction. All significant findings in univariate analysis were then entered into a multiple logistic regression model. The results indicated that the Beck Depression Inventory-II score (P = 0.011) and International Prostate Symptom Score (P = 0.043) were the only independent predictive factors of erectile dysfunction onset in these patients.

Conclusions: Hence, in order to provide an effective approach and management for erectile dysfunction all the mentioned symptoms and clinical variables should be kept in mind.
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http://dx.doi.org/10.5173/ceju.2017.1380DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5656369PMC
August 2017

Urodynamics before surgery for stress urinary incontinence in female patients: An open debate.

Arch Esp Urol 2017 Oct;70(8):691-694

Urology and Andrology Clinic. Department of Surgical and Biomedical Sciences. University of Perugia. Italy.

Currently the debate on the role of urodynamic tests in the preoperative evaluation of female stress urinary incontinence is alight. Although urodynamic investigation (UDI) has been considered mandatory before surgery in all female patients affected by stress urinary incontinence, nowadays international guidelines are more cautious. Literature on this topic has been reviewed in order to clarify the role of UDI before surgery for "complicated" and "uncomplicated" stress urinary incontinence in female patients. We focused on if and how UDI may improve clinical outcomes and alter clinical decision making. In conclusion, we believe that in most patients (the "complicated" ones) the role of UDI has not been fully evaluated. In "uncomplicated" cases, pretreatment UDI might not improve clinical outcomes but it could give important informations (voiding dysfunction in about 10% of cases) offering a valuable guide to the surgeon and to the patient. Interestingly though, UDI could alter clinical decision making being a valuable tool in counseling our patients with the aim of cure their symptoms, never risking of worsening them or causing further discomfort.
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October 2017